Polycystic Ovary Syndrome (PCOS): “Syndrome X of the Ovaries: Syndrome O”
I have already highlighted the importance of the Metabolic Syndrome X as a cause of much disability and premature death in women (and men). The variable combination of hypertension, high or abnormal blood cholesterol and an overweight status are fueled by insulin resistance. These problems form in the constellation of the Metabolic Syndrome X. I emphasize that there is still widespread lack of knowledge about the importance of Syndrome X in women’s health, especially in relationship to menstrual function.
While Syndrome X may be considered inappropriately as a typical male trait, less focus has been placed on the special significance of Syndrome X and insulin resistance for young women. The occurrence of cystic ovaries in young women has been quite clearly linked to Syndrome X. This condition is called polycystic ovary syndrome or Stein-Leventhal Syndrome. In popular medical literature, PCOS has been referred to as Syndrome X of the ovaries (or even Syndrome O). The typical female with PCOS is premenopausal, 18 to 28 years old, with variable degrees of overweight status, excess body hair, irregular menstruation, period pains (dysmenorrhea, PMS), acne and infertility.
To recognize the association of PCOS as part of Syndrome X further reinforces the far-reaching health consequences of the metabolic changes that occur with insulin resistance. As the name suggests, PCOS results in multiple cysts in the ovary. These ovarian cysts may be tiny and many in number. These small cysts are not often found during routine medical examinations. The cysts are often not felt by the examining physician during vaginal examination but they are readily seen on pelvic ultrasound studies. This makes PCOS an “occult” disorder and sometimes a difficult clinical diagnosis for many physicians.
The relationships between insulin secretion, female hormonal status and ovarian function are complex. In simple terms, the excess circulating insulin that occurs as a consequence of insulin resistance (Syndrome X) stimulates special cells in the ovary (theca cells) to produce increased amounts of male-type hormones (testosterone). In addition, the function of the pituitary gland becomes independently disturbed. This affects the secretion of hormones that regulate menstrual cycles and gonadal functions (sexual organ functions). In young women with PCOS, excess male hormones may cause excessive body hair of a male pattern of distribution, oily skin and infertility; and they may dramatically alter the menstrual cycle. The increasing emergence of PCOS has been a boon to the cosmetic industry that addresses skin aesthetics, without corrections of the underlying problems.
Syndrome X and Premenopausal Female
The serious challenge of Syndrome X to women’s health is the occurrence of major hormonal disturbances in premenopausal females in association with PCOS and insulin resistance. Some studies suggest that between 5% and 10% of all young women in the U.S. may have some form of Syndrome X of the ovaries or PCOS. How many have PCOS combined with PMS is not clear, but these disorders can go hand-in-hand.
I mentioned earlier and I repeat that the cysts that affect the ovaries in PCOS may not cause any symptoms and they are not always detected by a standard vaginal examination. However, they are readily detected by pelvic ultrasound. Common reasons for an individual with PCOS to consult their physician include acne, obesity, excessive body hair, menstrual irregularities and infertility. The diagnosis of PCOS requires some degree of acumen because it is possible to have several of these common disorders in the absence of PCOS. Unfortunately, PCOS can be confused with PMS, but I restate that these disorders may co-exist!
The exact cause of PCOS remains unclear, but there appears to be a genetic tendency in some women where there is increased sensitivity of the ovaries to the effects of insulin. The treatment of PCOS is undergoing continuous revision, but evidence has emerged that lifestyle change with weight loss, exercise and tailored nutrition can be highly effective. Of course, this is the common approach to manage Syndrome X itself. The emergence of PCOS is an example of how lifestyle can specifically affect reproductive health.
Although many of the symptoms and signs of PCOS improve with weight control and dietary change, I have experience with the successful use of beta glucan supplements, soy protein, alpha lipoic acid and fish oil. Each of these supplements may be quite beneficial for the natural management of PCOS and Syndrome X. Combinations of these dietary supplements have been used as part of a group of Syndrome X Nutritional Factors®. Management of the constellation of problems within Syndrome X requires an appropriate, but quite complex formulation of different natural substances. The range of Syndrome X Nutritional Factors® and their actions are discussed in Chapter 7 in more detail. Antidiabetic medication (e.g., Metformin) is sometimes used in the treatment of PCOS with good outcome. In summary, dietary supplements that overcome insulin resistance reduce elevated blood cholesterol, help normalize blood pressure and assist in weight control are key components within formulations of Syndrome X Nutritional Factors® (www.naturalclinician.com).
There are many ways to reverse insulin resistance in a natural manner. One universal approach is to correct deficiencies or imbalances of essential fatty acids of the omega-3 series. Improving the sensitivity of the actions of insulin can be achieved by weight control, cessation of smoking and exercise as well as the use of selected dietary supplements. With clarity, the natural substances that comprise Syndrome X Nutritional Factors® are to be used with positive lifestyle changes and diet in the combat against Syndrome X. A new discovery in the nutritional management of Syndrome X is the use of polyphenols found In Citrus bergamot (Holt S, The Antiaging Triad, 2011, www.stephenholtmd.com). I believe the inextricable linkage between PCOS and insulin resistance should precipitate prompt action to counter Syndrome X in many women with menstrual problems. A positive lifestyle and nutritional program to combat Syndrome X will promote general health, even if it does not provide complete management for the combined woes of PCOS and PMS. That said, I have seen many women with PMS and PCOS of varying severity respond in an extremely favorable manner to attempts to combat Syndrome X by natural means.
Conventional medicine has sometimes relied on treatment of PCOS with female sex hormones (birth control pills with low estrogen formulations) and insulin-sensitizing drugs. In addition, drugs that block the production of male sex hormones (androgen-blocking drugs, such as spironolactone or finasteride) have been used, but I believe that there is a special role for the use of phytoestrogens of natural origin, especially soy isoflavones and other selected natural substances including black cohosh and Dong quai.
In conventional medicine, drugs that promote insulin sensitivity have been used to manage PCOS. These drugs belong to a class of compounds called “glitazones” and their use has been overshadowed by serious adverse effects in some people. It should be noted that insulin-sensitizing medications do not lower blood sugar in people who do not have hyperglycemia, but these drugs can cause weight gain, liver problems, as can some hormonal treatments. The use of insulin – sensitizing drugs has diminished, given the serious potential adverse effects of Avandia®. Menopause is regarded as a “cure” for the common manifestations of PCOS or PMS, but insulin resistance continues after menopause and other consequences of Syndrome X and its associated diseases persist in the post-menopause.
Topical Biosimilar Progesterone
An interview between and Dr. John R. Lee, M.D., (best-selling author of the book “What Your Doctor May Not Tell You About Menopause”) and myself, was published on the front page of the July/August 2000 issue of Natural Pharmacy. In this interview, the late Dr. Lee revered the health benefits of natural progesterone applied to the skin for the support of premenstrual syndrome [PMS] and menopause.
Several authors have supported the strong assertions of Dr. Lee, that topical progesterone is well-absorbed and highly effective for the suppression of unpleasant symptoms of the menopause or PMS, without carrying the documented risks of conventional HRT. Several protagonists of natural therapies have ignited intense interest in the use of topical progesterone creams for a variety of women’s complaints. Several progesterone creams exist in the market, in various dosages, formulations, and dispensation systems, with or without the addition of other natural substances, such as phytoestrogens (soy or red clover isoflavones etc.). While progesterone is readily absorbed through the skin, its absorption can be highly variable depending on many circumstances such as blood flow to the skin, room temperature, quality of formulation of the cream, etc.
It is clear that requirements for progesterone applications can vary depending on a woman’s hormonal status. Women must educate themselves about sex hormones so that they can understand the indications for usage of progesterone cream, without entering circumstances of doubt. Women should obtain the advice of a skilled healthcare giver before any attempts to self-medicate. That said, unique dispensation systems of progesterone creams are available in convenient pumps. These dispensation pumps deliver predictable amounts of progesterone cream and they are the preferred way of using topical progesterone. There is no doubt that the application of progesterone cream involves some degree of trial and error to find an optimum required dosage.
Natural progesterone creams are not considered to be drugs at lower dosages (arguable), and they are not simple cosmetics, but I stress they should be used with supervision and self-education on hormonal needs. Topical progesterone should be used only by mature females, and it is not recommended for use in childhood or pregnancy. Over-dosing with progesterone or rapid transfer of progesterone into the bloodstream can cause troublesome side effects, such as dizziness, headache, and nausea.
Lifestyle and PMS
There is a clear indication in the medical literature that lifestyle influences the occurrence and severity of PMS. However, there is less recognition that PMS influences the quality of life of the afflicted which, in turn, affects the people who are exposed closely to the woman with PMS. Stress is a facilitator of PMS and any program to rid the symptoms of PMS must involve concentrated efforts to relieve stress and induce relaxation. I support every option available for stress reduction in the individual with PMS, including but not limited to all forms of natural medicine that induce a relaxation response. When hormonal imbalance occurs, women can be thrust into circumstances where even small stresses in life can provoke severe anxiety or negative changes in behavior.
Sleep Deprivation and PMS
I believe that one of the most important matters that aggravate PMS is the occurrence of sleep deprivation. Good sleep is the “king or queen” of a normal body biorhythm. Sleep deprivation turns on stress hormone responses which can result in anything ranging from insulin resistance and weight gain through to water retention and fatigue. All natural approaches to restful sleep must be considered in the woman with PMS because such women are of great risk of developing dependence (addiction) on alcohol or tranquilizing drugs or sleeping pills (Holt S, Sleep Naturally, 2003, www.stephenholtmd.com). The initial benefit experienced by taking tranquilizers and sleeping tablets is replaced by a legacy of potential hurt when these drugs are withdrawn. Drinking alcohol excessively can provide a great escape in life but alcohol can cause major disturbance in hormone chemistry in the body and it pushes mood in all directions. Nutritional support for sleep is of great value (www.naturalclinician.com).
PMS and Body Weight
Obesity or being overweight commonly goes hand in hand with PMS and weight gain is a major problem for peri-menopausal women. Changes in mood and social circumstances lead some women to seek solace in food. Men and women often deal with mental upset by clutching for food in a frequently failed attempt to counter discontentment. Women in modern society respond strongly to the cosmetic aspect of weight control, but their real motivation should lie more in the realization that fat deposits in the body cause much potential harm to health. These fat deposits contribute greatly to hormonal imbalances as well as chronic disease.
Deposits of fat in the body can produce estrogen by converting other sex steroids. For example, androstenedione is a hormone often found in excess in the overweight person. This hormone is readily converted to estrogen, as are hormones or their precursors such as DHEA or cholesterol. The obese woman tends to have estrogen dominance which contributes to PMS and other diseases associated with obesity in women such as breast, ovarian and uterine cancer. Again, I refer to the Metabolic Syndrome X and its wide-ranging association with many diseases. Weight control is a major treatment intervention for the overweight woman with PMS (Holt S, The HCG Diet Revolution, 2011, www.stephenholtmd.com).
A Diet for PMS?
Food craving or specific taste cravings occur often in the woman with PMS. These cravings include uncontrollable desires for sweet foods, junk foods, candy, salt and chocolate. When women give in to these cravings, symptoms of PMS can become worse. For example, excessive salt in the diet promotes thirst, adds to body water gain (swelling or edema) and it causes rises in blood pressure. Excessive intake of sweet foods such as doughnuts and Twinkies can cause roller coaster increases in blood sugar that are followed by periods of low blood sugar (hypoglycemia). Unfortunately, the real danger of these kinds of dietary habits is the promotion of weight gain and the Metabolic Syndrome X. I restate that Syndrome X is associated with hormonal imbalance itself and the polycystic ovary syndrome (PCOS).
I have found that many women with PMS benefit from dietary interventions that can slow down the absorption of sugars, to keep blood sugar levels on an “even” keel throughout the day (Syndrome X Nutritional Factors®). Fluctuations of blood sugar with attacks of hypoglycemia are a common cause of aggravation and propagation of symptoms in PMS. The rapid rises and falls of blood sugar on the average American diet can be changed by soluble fiber intake. This is part of what is evolving as “the slow carbohydrate diet” (www.naturalclinician.com).
Nutrition and PMS
Several studies have attempted to define nutritional deficiencies in women with PMS, but no specific nutrient deficiency has been consistently implicated as a cause of PMS. Certainly, poor diet contributes to PMS and the best diet is a diet that will promote global health. In brief, a diet for PMS cannot be characterized specifically, but an optimal diet would be controlled in calories, low in salt, nutrient-dense, reduced in meat or dairy protein, enhanced in vegetable protein (e.g., soy) or fish protein, low in simple sugars, high in omega-3 fatty acids, reduced in saturated fat and rich in fiber. Every woman with PMS should take a daily multivitamin and daily mineral supplement. Specific vitamins that have been identified to be of benefit in PMS include the vitamin B complex, beta carotene and fish oil. Fish oil contains essential fatty acids (Omega 3 fatty acids, EPA and DHA) that are not manufactured by the human body; and these types of fat are as essential as any vitamin (www.naturalclinician.com).
PMS Eludes the Quick Fix
I trust that it is clear from this discussion that the approach to managing PMS does not rest entirely in a quick rub of topical progesterone cream, even though progesterone cream may be valuable in many circumstances. The conundrum of PMS requires a multipronged, socio-behavioral and positive-lifestyle approach with consideration for first-line, natural medical options. Jumping to drugs in PMS has more disadvantages than advantages for many women. We should remember that the same philosophy holds true for the menopausal transition.